If you are a mental/behavioral health provider then you might be familiar with BIRP notes. BIRP notes are a notetaking format that therapists might use to document sessions in clinical records. Therapists are infamous for their notetaking. In every movie with a mental health provider, you see them scribbling things in a notebook right in front of their patients. The reality is that the documenting of clinical notes is important for billing, the tracking of progress, and keeping providers organized. What are BIRP notes, how are they used, and how are they different from other notetaking styles?
The Composition of Clinical Records
Clinical records are an important piece of the mental health profession. Having detailed records is what helps improve the quality of care and the tracking of a client’s overall progress. So what makes up a clinical record?
Patient Information (Name, DOB, demographics, etc.)
Reason for Seeking Services (Depression, Anxiety, Stress, etc.)
Diagnosis and Impression
What are BIRP Notes?
The acronym for BIRP notes stands for Behavior, Intervention, Response, Plan. It is a format of notetaking that helps mental health providers track patient progress and formulate plans for the future. The formatting of notetaking enables providers to document efficiently without missing details.
The behavior section of BIRP notes is dedicated to how the client presents themselves, the problem, their “behavior” and other observations of both subjective and objective details. This section might include things the client said during their session, their responses to certain questions, their mood, or different emotions they expressed, how they carried themselves, and more. For example, if the client presented themselves as frustrated or responded to certain questions with hesitation, those things would be noted in this section. If they said, “that really made me feel ___,” a therapist might also write that in this section as a quote.
This section of BIRP notes is less about what was observed and more about the methods used to work with the client to reach goals, uncover information, or guide them through their next steps. It should be a detailed account of the session, not from the client’s actions, but from the therapists. This section might include certain interventions you used, what questions you asked (and why), or changes you decided to make to the treatment plan while it was unfolding.
In the first two sections of BIRP notes, you detailed the client’s emotions, behaviors, and responses to certain questions or topics as well as what methods you used during the session. The Response section should be dedicated to an in-depth analysis of the client’s responses to the interventions you chose to use. Rather than use vague terms like “they were angry,” a therapist might write, “They were frustrated when I asked them ___ and responded by saying ___. It took them a few seconds to gather their thoughts to formulate a response.”
The Plan section of BIRP notes is meant to detail the action plan for the next session and on. In a field like mental health, treatment plans require a certain fluidity. BIRP notes enable a provider to plan from a visit to visit depending on how the session went, what information was uncovered/discussed, and what the client hopes to work on in the future. This section should detail the time and place of the next appointment, what interventions the therapist plans to use, and what topics will be addressed. For example,
Other Documentation Models:
Some of the most common documentation models other than BIRP notes include SOAP notes and DAP notes. SOAP notes originated in healthcare as a model to streamline the notetaking process. Due to the fact that mental health care is less black and white compared to healthcare, some therapists prefer DAP notes. DAP notes offer more room for subjectivity in notetaking, but unlike BIRP notes, include an assessment section.
SOAP, DAP, and BIRP notes all aim to streamline the notetaking process. They are all effective ways for standardizing the documentation process so that providers do not spend an unnecessary amount of time on it, but are still a reliable source of information regarding the session. All are used for billing, planning, and progress tracking purposes.
The best and simplest way to document easily and effectively is to adopt a notetaking software. Certain notetaking solutions come with BIRP note formatting options, as well as other options, to help record information digitally in a secure and accessible way.
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